Medical Insurance Frustration

[Davs2601]

We are currently having issues with our two medical insurances and I need some advice on who to talk with.

We have two health insurance policies Wife = Health Choice, Me = Blue Cross Blue Shield Fed

Son had tubes put in on May 2nd and we received a bill for $700. The primary (HC) paid $900 then BCBC paid in $200 to bring it up to their max allowable ($1100) for the procedure. BCBS says this is correct and the surgery center is saying they are wrong and should pay the full amount up to $1100 which would cover the balance of $700

I have had lengthy discussions with them both and I'm not getting anywhere, but one of them appears to be lying about the situation. One of two things should happen, the surgery center accepts the $1100 max allowable charge regardless of 1 or 2 insurance policies or BCBS should cough up more $. I have them as a full blow secondary insurance and not a supplemental insurance. I pay my premiums so that they cover XX% of procedures.

My daughter had tubes put in in 2009 = No Charge to us
My wife gave birth to my son in 2013 = No Charge to us

Not sure what has changed since I am still using a provider that is "In Network"

Any advice or know who I should talk with?? If I owe Ill pay my debt, I just feel this is being processed improperly and the two sides can get on the same page.

 

[SlugSlinger]

You need to find a copy of your current policy to find what it says in writing. It should be outlined in the policy and you can provide, in writing, the document showing they are wrong. Otherwise, it's just talk and can go on forever with no or the wrong resolve.

We are currently having issues with our two medical insurances and I need some advice on who to talk with.

We have two health insurance policies Wife = Health Choice, Me = Blue Cross Blue Shield Fed

Son had tubes put in on May 2nd and we received a bill for $700. The primary (HC) paid $900 then BCBC paid in $200 to bring it up to their max allowable ($1100) for the procedure. BCBS says this is correct and the surgery center is saying they are wrong and should pay the full amount up to $1100 which would cover the balance of $700

I have had lengthy discussions with them both and I'm not getting anywhere, but one of them appears to be lying about the situation. One of two things should happen, the surgery center accepts the $1100 max allowable charge regardless of 1 or 2 insurance policies or BCBS should cough up more $. I have them as a full blow secondary insurance and not a supplemental insurance. I pay my premiums so that they cover XX% of procedures.

My daughter had tubes put in in 2009 = No Charge to us
My wife gave birth to my son in 2013 = No Charge to us

Not sure what has changed since I am still using a provider that is "In Network"

Any advice or know who I should talk with?? If I owe Ill pay my debt, I just feel this is being processed improperly and the two sides can get on the same page.

 

[tRidiot]

You need to find a copy of your current policy to find what it says in writing. It should be outlined in the policy and you can provide, in writing, the document showing they are wrong. Otherwise, it's just talk and can go on forever with no or the wrong resolve.

Unfortunately, it will say something like it will pay up to the "approved rate". Sounds like they're claiming they'll pay up to the approved rate... from all carriers combined. Pretty standard ins company fare.

 

[tRidiot]

You need to find a copy of your current policy to find what it says in writing. It should be outlined in the policy and you can provide, in writing, the document showing they are wrong. Otherwise, it's just talk and can go on forever with no or the wrong resolve.

Unfortunately, it will say something like it will pay up to the "approved rate". Sounds like they're claiming they'll pay up to the approved rate... from all carriers combined. Pretty standard ins company fare.

Maybe make a call to the insurance commission?

 

[JD8]

IN a nutshell BCBS is right IMO and I absolutely hate saying that because they are such a bassackwards company. Under the COB provision they are not required to cover something that is above and beyond what they state is customary for that procedure, typically, even if another company pays part of the claim. Protects them from double indemnity.

http://personalinsure.about.com/od/insurancetermsglossary/g/coordination-of-benefits.htm

FWIW, until recently I dealt with health care providers on a daily basis and typically their front office had no clue when it came to claims, billing, what the law says, and policy coverages. So take what they say with a grain of salt. You should be able to get some help from your HR or plan administrator.

 

[tRidiot]

^^^^What he said.


And for any of you on Medicare with a secondary provider to whom you're paying a premium, I sure hope it ain't much... that situation's even worse. In most cases, they're not gonna pay anything.

 

[JD8]

Med Supp companies SHOULD pay as they are responsible for what medicare tells them to pay. They really have no choice, once medicare fires off the claim, med supp companies have to pay the remainder up to 15% above what medicare says is allowable IF they have certain plans. If they don't.....

 

[SMS]

Reads to me like the provider is trying to get more than the max allowable charge for the procedure.

By agreeing to be "in the network" the provider can only charge what the plans allow. That max doesn't change just because you have more than one policy. (At least that's how it works for me).

 

[EhlerDave]

^^^^What he said.


And for any of you on Medicare with a secondary provider to whom you're paying a premium, I sure hope it ain't much... that situation's even worse. In most cases, they're not gonna pay anything.

Oh man that is a subject that gets touchy here. I have a real messed up neck, I have been getting shots for almost 13 years so I can turn my head to the right. The surgery to TRY repairing the problem is very risky, then my EDS just makes it worse. But as of the new ocare crap going into effect my shots, most last 6-8 months, have been deemed "No longer medically necessary." Due to Medicare rules I can't even pay for them ($125) out of pocket or the Dr could get his license pulled.

 

[tRidiot]

Med Supp companies SHOULD pay as they are responsible for what medicare tells them to pay. They really have no choice, once medicare fires off the claim, med supp companies have to pay the remainder up to 15% above what medicare says is allowable IF they have certain plans. If they don't.....

If a provider agrees to accept Medicare assignment, they also agree to perform procedures for Medicare's approved cost and cannot bill over and above that, even to a secondary. Thus, secondary insurance providers in this scenario pay nothing, although the insured has been paying premiums for who knows how long thinking, "I'm double-covered, yay me!" An alternative is not to accept Medicare assignment and negotiate each potential interaction on a case-by-case basis. This was the situation for a friend of mine who was a surgeon. Unfortunately, he has since been forced to accept Medicare assignment as a result of the manipulation and regulation (read: destruction) of the free market and is having to play dumbed-down and "lowest-common-denominator" medicine to stay alive.

Thanks .gov. Great work.